Board and Care Homes

Encyclopedia of Aging
COPYRIGHT 2002 The Gale Group Inc.

BOARD AND CARE HOMES

Board and care homes are a communitybased residential option for older adults requiring care and services. As part of the continuum of care from home to nursing home, they assist primarily those not needing nursing or medical care but unable to live independently due to physical or cognitive impairments. Homes range in size and in extent to which the environment is institutional, from very small, family-style, residential settings in communities of single-family homes to larger, multiroom, more "institutional" facilities (Morgan et al., 1995). Regardless of size, board and care facilities offer residents shelter (room), meals (board), twenty-four-hour supervision, and a range of services, often for a minimal cost.

Defining board and care

The legal definition of what constitutes a board and care home depends on local, state, and national statutes, and is related to the health and welfare agencies that monitor homes. Nomenclature varies widely. As noted by Robert Rubinstein, the middle range of care settings includes such alternatives as sheltered housing, domiciliary care, adult foster care, small congregate homes, and assisted living. The same name may be used for different types of settings in different states, making it hard to distinguish board and care facilities (McCoy and Conley). However, the term "board and care" is often used to describe
the range of non-nursing home care arrangements, including many of those listed above.

Distinctions between board and care and "assisted living" are blurred. Assisted living is the name given to a consumer-focused residential model emphasizing privacy, independence, decision making, and autonomy. Moreover, the label "assisted living" has been used to differentiate this type of housing from conventional board and care housing and the negative connotations that some people associate with it (GAO, 1992; Kane et al.). In many states considerable overlap exists between board and care and assisted living, and the terms may be used interchangeably (Mollica).

Size is often a distinguishing feature in board and care settings. In particular, small board and care homes are often distinguished from larger, multiunit, purpose-built facilities. Both size and coresidence of the operator differentiate small, family-type homes from larger, more institutional, staffed homes. Studies of small board and care homes have found them to be much like extended family settings in single-family homes. The majority of small home operators are middle-aged women, many of whom have limited education (Morgan et al., 1995). Living spaces and meals are often shared in these small homes, which are believed to serve a more vulnerable adult population who are poor, have inadequate kin and other support, and suffer from long-term disabilities, mental illness, mental retardation, and chronic physical conditions (Eckert and Lyon).

Estimated numbers of beds

The number of board and care facilities is difficult to establish, since there is no generally accepted definition of what constitutes such a facility or any systematic way to count them. With the emergence of purpose-built facilities offering assisted living services during the 1990s, the numbers of older adults being served in nonmedical care settings has increased substantially. Prior to the boom in assisted living, a 1987 industry survey identified about 563,000 board and care beds in 41,000 licensed homes nationally. A 1992 GAO study found some 75,000 licensed and unlicensed homes serving a million people, including half a million disabled older adults. A 1999 GAO report on assisted living that includes board and care facilities, estimates the number of beds in the United States at between 800,000 and 1.5 million. The report notes that consumer demand is expected to grow significantly as the projected number of elderly Americans in need of long-term care doubles between 2000 and 2020.

Resident characteristics

Studies of home residents find that most of them are older, frequently widowed, and lacking proximate kin (Morgan et al., 1995). Some homes accept younger physically or mentally disabled adults as well as elderly residents. In the mid-1980s it was estimated that older people constitute 40 to 60 percent of the board and care population, with the largest category of residents being older, functionally impaired women (Dobkin).

Most home residents have multiple health problems or cognitive problems that make it risky or impractical to live independently (Dittmar and Smith; Morgan et al., 1995). In many cases the number of limitations in Activities of Daily Living among residents in board and care homes approaches that found among nursing home residents (Morgan et al., 1995; Morgan et al., 2001).

In small homes, a high percentage of residents are economically disadvantaged, receiving support from Supplemental Security Income or state programs to provide for their care (Morgan et al., 1995). Fees that residents pay for care and housing come from state-funded programs, personal savings, Social Security or other retirement benefits, family contributions, or private insurance. Since fees range from a few hundred dollars to several thousand dollars per month, board and care has met a need to provide an alternative for low-income elderly persons, who would be unable to afford the newer assisted-living facilities on meager private resources.

Services

The goal of board and care facilities is to provide housing and supportive services to individuals who are sufficiently impaired to require regular assistance with or supervision of daily tasks but are not in need of medical intervention (i.e., nursing care) on a regular basis. As with many older adults, needs at these midlevel facilities are for assistance with personal care, mobility, and supportive services, such as meals, laundry, medication management, and housekeeping.

The services provided in board and care homes, while variable across facilities, focus on helping with the daily tasks and personal care needs of residents, rather than with health care services. The range of services provided to residents is quite broad, responding both to their diverse needs (driven by both physical and cognitive impairments) and to variations among the facilities in terms of size, willingness to deal with more difficult or advanced care needs, and the fees paid for care (Morgan et al., 1995). Some homes offer a substantial range of services, while others provide a limited set at lower cost. In general, however, basic services to residents include meals, room, twenty-four-hour oversight, assistance in personal care (bathing, dressing, etc.), homemaking services, and assistance with mobility and with taking medications (Morgan et al., 1995). In addition, recreation, transportation, beautician/barber, and laundry services may be included. To the extent that homes attempt to keep residents from relocating to nursing homes, more advanced care may also be arranged, including assistance with feeding, toileting, mobility, and orientation, and even some nursing services. These services, enabling homes to keep residents and permit them to "age in place" as health declines, may be provided outside the home or by outside service providers delivering care within the board and care home.

Funding and regulation

The topics of funding and regulation are typically discussed together, since they are related. For much of its history, board and care has operated as a "grassroots" option, out of view of public funding and regulation (Morgan et al., 1993; Nolin and Mollica, 2001). While public sources of funding have been unavailable throughout most of this history, board and care homes have also, until recently, been largely unregulated, especially if they are small (Morgan et al., 1995). Given that public funding has focused on medical needs of older adults via Medicare, and nursing homes via Medicaid, the nonmedical housing and support provided by board and care homes has been privately paid by most residents or their families. In some cases, state programs have provided support to the poorest elders living in board and care homes (Dobkin, 1989).

That situation has been changed by the utilization of Medicaid waiver monies and funds to support community-based care, thus providing public monies to support the care of older adults residing in board and care homes in some states. This change has been motivated by the generally lower costs for board and care than for nursing homes, with the expectation that public costs overall would remain lower for individuals able to remain in board and care facilities rather than nursing homes (Nolin and Mollica, 2001).

At the same time that funding is beginning to flow from federal sources, states are moving rapidly in the direction of regulating smaller, non-nursing home facilities, driven both by the boom in assisted living and by the earlier reports of poor care in board and care homes (GAO, 1992). State regulations include size requirements, staffing, services, whether units may be shared, transfer policy, and resident rights (see Mollica, 2001). It is unclear whether board and care will flourish, change, or disappear under the dual thrusts of state regulation and the growth in private-pay assisted living facilities.

Kane, R.; Wilson, K. B.; and Clemmer, E. Assisted Living in the United States: A New Paradigm for Residential Care for Frail Older Persons. Washington, D.C.: American Association of Retired Persons, 1993.

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Group homes

Group homes

Definition

Group homes are small, residential facilities located within a community and designed to serve children or adults with chronic disabilities. These homes usually have six or fewer occupants and are staffed 24 hours a day by trained caregivers.

Description

Most group homes are standard, single-family houses, purchased by group home administrators and adapted to meet the needs of the residents. Except for any adaptive features such as wheelchair ramps, group homes are virtually indistinguishable from other homes in the surrounding neighborhood. Group homes may be located in neighborhoods of any socioeconomic status.

Residents of group homes usually have some type of chronic mental disorder that impairs their ability to live
independently. Many residents also have physical disabilities such as impairments of vision communication, or ambulation. These individuals require continual assistance to complete daily living and self-care tasks. Some also require supervision due to behavior that may be dangerous to self or others, such as aggression or a tendency to run away.

Although most group homes provide long-term care, some residents eventually acquire the necessary skills to move to more independent living situations. Group homes for children are usually temporary placements, providing care until a foster family can be secured. Others may return to their natural families. Occasionally, halfway homes for people recently released from prison or discharged from a substance abuse program may also be referred to as group homes. These types of group homes are also transitory in nature.

History and mission

The development of group homes occurred in response to the deinstitutionalization movement of the 1960s and 1970s. As psychiatric hospitals closed, discharged individuals needed places to live. Group homes were designed to provide care in the least restrictive environment and to integrate individuals with disabilities into the community, reducing stigma and improving quality of life. The environment of a group home was intended to simulate typical family life as much as possible.

Since the passage of the Community Mental Health Centers Act in 1963, grants have been available to group homes. State and federal funds such as the Medicaid Home and Community-Based Waiver continue to support the majority of group homes. However, some homes operate on donations from private citizens or civic and religious organizations. Most group homes are owned by private rather than governmental organizations, and can be either non-profit or for-profit organizations. Group homes are considered more cost effective compared to institutional care. Unfortunately, the number of available group homes has not always matched need, resulting in homelessness or re-hospitalization for some individuals.

One of the goals of group home living is to increase the independence of residents. Group home staff members teach residents daily living and self-care skills, providing as little assistance as possible. Daily living skills include meal preparation, laundry, housecleaning, home maintenance, money management, and appropriate social interactions. Self-care skills include bathing or showering, dressing, toileting, eating, and taking prescribed medications.

Staff also assure that residents receive necessary services from community service providers, including medical care, physical therapy, occupational therapy, vocational training, education, and mental health services. Most group home residents are assigned a case manager from a community mental health center or other government agency who oversees their care. Case managers review group home documentation regarding skills learned and services received, and make recommendations for adjustments in care.

The NIMBY phenomenon

Unfortunately, group homes have received much opposition from communities. NIMBY (acronym for Not In My Backyard) describes the common reaction of community residents when they discover that a group home is targeted for their neighborhood. Current research suggests that protests frequently involve concerns over personal security, declining property values, or a generalized threat to the neighborhood's quality. Some researchers believe that prejudiced attitudes such as ignorance, fear, and distrust are the true reasons for protest.

Usually, neighborhood opposition is unsuccessful due to provisions of the Fair Housing Act of 1968. However, such opposition can be detrimental to the goal of integrating residents into the community. The NIMBY phenomenon is also a concern because as deinstitutionalization continues, the need for additional group homes increases. Statistics show that between 1987 and 1999, the use of group homes serving individuals with developmental disabilities and containing six residents or less increased by 240%.

Social service workers are constantly looking for ways to address the NIMBY phenomenon. Some research has suggested that community concerns decrease with time as community members become familiar with group home residents. A recent study proposed that opposition can be decreased by providing advanced notice of plans for a group home, as well as adequate information and discussion about expectations.

Factors affecting group home success

Initially, many people were skeptical about the adequacy of group home care compared to psychiatric hospitals or other institutions. Over the past 25 years, many studies have examined the impact of group home care on residents. These studies have consistently shown increases in adaptive behavior, productivity, community integration, and level of independence.

Risks involved in successfully transitioning an individual to a group home include psychological deterioration
such as severe cognitive or physical impairments, physical deterioration that includes being non-ambulatory, or mortality issues such as being age 70 or older.

Before considering group home placement—especially for those in the high-risk category—extensive planning should be conducted. A complete assessment plan of the individual's needs should specify which agency will be responsible for meeting medical needs, particularly in the event of a crisis. The individual's strengths should be incorporated into the plan whenever possible. For example, if a supportive family is an identified strength, the preferred group home should be close in proximity to facilitate family visits.

Other factors that contribute to group home success are a small staff-to-resident ratio, well-trained staff, and a home-like atmosphere. As with any type of organization, some group homes are better run than others. A careful investigation into a home's procedures is recommended. Research suggests that individuals with severe cognitive impairments often experience a period of disorientation, and may need additional support or supervision for the first few months while adjusting to their new surroundings. Pre-placement visits and discussion can reduce anxiety for the future resident.

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